多机构分析儿科与成人患者的胆总管结石病。
Multi-Institutional Analysis of Choledocholithiasis in Pediatric vs Adult Patients.
机构信息
Children's Healthcare of Atlanta, Atlanta, USA.
Wake Forest School of Medicine, Winston Salem, USA.
出版信息
J Pediatr Surg. 2024 Dec;59(12):161661. doi: 10.1016/j.jpedsurg.2024.08.001. Epub 2024 Aug 13.
BACKGROUND
In adults, upfront intraoperative cholangiogram with laparoscopic common bile duct exploration (LCBDE) is well accepted for management of choledocholithiasis. Despite recent evidence supporting LCBDE utility in children, there has been hesitation to adopt this surgery first (SF) approach over ERCP first (EF) due to perceived technical challenges. We compared rates of successful stone clearance during LCBDE between adult and pediatric patients to evaluate if pediatric surgeons could anticipate similar rates of successful clearance.
METHODS
A multicenter, retrospective review of pediatric (<18 years) and adult patients with choledocholithiasis managed from 2018 to 2024 was performed. Demographic and clinical data were obtained. Rate of successful duct clearance with LCBDE was compared. Surgical and endoscopic complications (infections, bleeding, pancreatitis, bile leak) were also compared.
RESULTS
724 patients, 333 (45.9%) pediatric and 391 (54.0%) adults, were included. The median age of pediatric vs adult patients was 15.2 years [13.1, 16.6] vs 55.5 years [34.1, 70.5], respectively. Of these, 201 (60.4%) pediatric vs 169 (43.2%) adult patients underwent SF, p < 0.001. LCBDE was attempted in 84 (41.7%) pediatric vs 140 (82.8%) adults, p = 0.002. LCBDE success was higher in pediatric vs adult patients (82.1% vs 71.4%, p = 0.004). Complications rates were similar however, pediatric patients who underwent EF had higher endoscopic complications (9.1% vs 3.6%, p = 0.03).
CONCLUSION
LCBDE is highly successful in children vs adults with no increased surgical complications. This data, coupled with the limited ERCP access for children, supports that LCBDE is an equally effective tool for managing choledocholithiasis in children as is accepted in adults.
LEVEL OF EVIDENCE
Level III.
背景
在成人中，腹腔镜胆总管探查术（LCBDE）术中即时胆管造影术已被广泛接受，用于治疗胆总管结石。尽管最近有证据支持 LCBDE 在儿童中的应用，但由于技术挑战，人们一直犹豫不决，是优先采用这种手术方式（SF）还是优先采用内镜逆行胰胆管造影术（EF）。我们比较了成人和儿科患者在 LCBDE 中结石清除的成功率，以评估小儿外科医生是否可以预期类似的成功清除率。
方法
对 2018 年至 2024 年期间接受治疗的患有胆总管结石的小儿（<18 岁）和成人患者进行了多中心回顾性研究。获取了人口统计学和临床数据。比较了 LCBDE 成功清除胆管的比率。还比较了手术和内镜相关并发症（感染、出血、胰腺炎、胆漏）。
结果
共纳入 724 例患者，其中 333 例（45.9%）为儿科患者，391 例（54.0%）为成人患者。儿科患者的中位年龄为 15.2 岁[13.1，16.6]，而成年患者的中位年龄为 55.5 岁[34.1，70.5]。其中，201 例（60.4%）儿科患者和 169 例（43.2%）成年患者接受了 SF 治疗，p<0.001。84 例（41.7%）儿科患者和 140 例（82.8%）成年患者尝试了 LCBDE，p=0.002。LCBDE 的成功率在儿科患者中更高（82.1% vs 71.4%，p=0.004）。然而，并发症发生率相似，但是接受 EF 治疗的儿科患者内镜相关并发症发生率更高（9.1% vs 3.6%，p=0.03）。
结论
LCBDE 在儿童中的成功率非常高，与成人相比，手术并发症没有增加。这些数据，加上儿童有限的 ERCP 通道，支持 LCBDE 作为一种同样有效的治疗儿童胆总管结石的工具，与成人一样被接受。
证据水平
III 级。
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